AUTHORIZATION AGREEMENT FOR ACH DEBIT

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AUTHORIZATION AGREEMENT FOR ACH DEBIT Powered By Docstoc
					                                                            Return this form to:

                                                            Accounts Receivable Department
                                                            PO Box 2778
                                                            Bismarck, ND 58502-2778

                                                            Fax Number: (866) 415-2232


              AUTHORIZATION AGREEMENT FOR ACH DEBIT
Member(s) Name: __________________________________________
Medicare Insurance Claim Number (On Red, White and Blue Medicare Card): _____________________

Bank Account Type:          Checking Account            Savings Account *

Name on Account: _______________________________________________

Bank Name:          _______________________________________________

Bank Address:        _______________________________________________

Bank ABA Number:___________________________ (nine-digit number at bottom left corner of check)

Account Number:      _________________________________

IMPORTANT NOTE: Please attach a voided check or voided savings account withdrawal slip
along with this form
*No passbook savings accounts
      I agree that this authorization will remain in effect until I provide written notification terminating
this service. Request must be received before the 1st of the month of the ACH transaction. (ACH
transaction will occur on the 10th of the month in the amount of the balance due for the current month.)
Fax or Mail the completed form and a voided check to the address printed on the top of this form.
__________________________________________                   __________________
Signature                                                    Date
If you are the authorized representative, you must sign above and provide the following information:

Name : ________________________________________________
Address: ____________________________________________________
Phone Number: (___) ________- ___________
Relationship to Enrollee _______________________________


               A Coordinated Care plan with a Medicare Advantage contract
M0003_09MAPDPFFS_655_ACHDbtForm                          CMS File & Use Date: 04/07/2009

Advantra is offered by Coventry Health Care of Kansas, Inc (HMO) and Coventry Health and Life
Insurance Company (PPO)
                        Information About The Kansas Advantra
                           Automatic Premium Payment Plan

What is Kansas Advantra’s Automatic Premium Payment Plan?
The Automatic Premium Payment Plan is a convenient way to make your monthly plan premium
payments to Kansas Advantra. To begin, you sign an authorization form which allows Kansas Advantra
to withdraw your monthly plan premium payment from your checking or savings account on the 10th of
each month. You would then simply deduct the payment from your checkbook each month.

What are the benefits of using the automatic premium payment plan?
Your monthly plan premium payments would automatically be paid each month so there is no worry of
getting behind in your payments. In addition, you have the peace of mind in knowing that your monthly
plan premium payments are paid on time even if you happen to be traveling at the time the payments
become due.

Does my bank participate?
You can check with your financial institution, however, direct debiting can be coordinated with
practically every bank, saving and loan, and credit union in the United States.

What if I change banks or bank accounts?
You will need to complete a new authorization form. Simply call Customer Service at the telephone
number that appears on the back of your Identification Card and ask us for a new authorization form.
You’ll want to fill it out with your new bank information and return it to us no later than the 5th of the
month so we can change the automatic deduction to come from the appropriate bank account on the 10th
of the month. If you do not send us a new authorization form with the correct bank and account
information, or wait until after the 5th of the month to submit it, we will still attempt to automatically
deduct your monthly plan premium for the account we have on file from you.
If we receive notice from the bank that there are no funds available or that the account has been closed,
you will be notified in writing and you will be asked to pay your monthly plan premium payment directly
to us. In addition, you will be responsible for any fees incurred by your bank, such as non-sufficient
funds (NSF).

How do I terminate my monthly bank deduction?
Termination requests must be faxed and received prior to the end of the month before the termination
date (ex: Termination 10/01 must be received by 9/30). Your automatic withdrawal will not stop unless
the termination request is received by the end of month prior to the next withdrawal. Termination requests
can be faxed to (866) 415-2232, Attention: Accounts Receivable Department. Termination requests will
be processed in the order received. You will be responsible for any fees incurred by their bank, such as
non-sufficient funds (NSF).

How do I know the withdrawal has been made from my account?
Most financial institutions will indicate the withdrawal on your bank statement. A few institutions will
include a paper document with your statement.




Advantra is offered by Coventry Health Care of Kansas, Inc (HMO) and Coventry Health and Life
Insurance Company (PPO)

				
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